The Fraught Establishment and Early

The first nurses had already entered the houses by mid-September. They were sitting with the dying. They were carrying the dead. They were also beginning to sicken. But the houses were not enough. A city that had lost its government, lost half its population, and lost the ordinary machinery of care needed somewhere to put the sick who had no one left to sit with them. The Committee of Twenty, meeting daily in the empty rooms of City Hall, faced this question as a matter of physical logistics before it became one of medicine or conscience. They needed a building.

The committee had been born of necessity. Mayor Matthew Clarkson and a group of prominent citizens who had stayed behind when the federal government fled now exercised a sovereignty of care over a population that had no other authority to appeal to. Their powers were undefined. Their mandate was survival. They kept minutes that read like dispatches from a besieged garrison: requests for carts, for nurses, for coffins, for money to pay for coffins. The dead were accumulating faster than the living could bury them. The sick were lying in houses where every other person had fled or died. Children were found beside parents who had been dead for days. Shelter came before treatment on the committee’s list of problems, and shelter was the harder of the two.

Someone raised the name of Bush Hill. The estate sat on a rise north of the city proper, a Georgian mansion on acres of ground that had been the country seat of the Hamilton family. Andrew Hamilton had built it in the early decades of the century, a gentleman’s house with outbuildings, stables, and land enough to breathe. It had passed through the family for decades. By 1793 it was unoccupied, its owner absent, its rooms standing empty through the late summer heat. The committee did not have time to deliberate over property rights. They needed walls and a roof, and Bush Hill had both. The estate was pressed into service as a hospital for the fevered poor, a transformation so abrupt that no one recorded whether the owner was asked or merely informed.

The building was filthy. That was the first report. The mansion had stood empty long enough to accumulate dust, vermin, and the general decay of a property without a household to maintain it. The committee sent men to assess it. What they found was a structure sound enough to hold people but unprepared to hold sick ones. There were no beds. There was no food, no medicine, no supplies, no staff. There was no order. The first patients arrived before any of these deficiencies had been addressed, carried up the hill on carts and laid on the floors of rooms that still smelled of disuse. The committee had found its building. A hospital was another matter.

What it needed was someone willing to run one. The committee’s members were merchants, politicians, clergymen. None of them had medical training. None of them had managed an institution of this kind. The city’s existing poorhouse, the Bettering House, was already overwhelmed, its wards packed with fever patients and its staff diminished by flight and illness. Bush Hill required a different kind of administrator: someone who could impose order on chaos, procure supplies from a city where commerce had collapsed, and manage the daily operations of a facility receiving the dying. The committee needed a particular combination of competence and willingness that was rare in a city where most competent people had left.

Stephen Girard volunteered. He was a merchant, a French-born naturalized citizen of Philadelphia whose trading house handled sugar, coffee, and the other commodities that moved through the Delaware port. He had not fled. He had stayed in the city through the worst weeks of the epidemic, and when the committee’s need became known, he offered his services. The decision was his alone. Girard was a man who had built his fortune through precision, calculation, and an unflinching attention to detail. He kept ledgers that recorded every transaction to the penny. He managed ships, cargoes, and correspondents across the Atlantic with a methodical discipline that his contemporaries recognized as extraordinary. He held no medical degree and made no claim to one. Nor was he a philanthropist in the sentimental sense that the word later acquired. He was a merchant who saw a problem that required management and decided to manage it.

The committee accepted. What they received was not a medical director but an organizer, a man whose instinct was to treat the hospital as he would treat a failing venture: assess the assets, identify the deficits, procure what was missing, and impose systems where none existed. Girard arrived at Bush Hill to find an institution in name only. The building was there. The patients were there. Almost nothing else was.

His first actions were practical. He inventoried what the estate contained, which was little. He assessed the staff, which was insufficient and in some cases unwilling. He began procuring supplies: bedding, food, candles, medicine, the basic material requirements of a facility that needed to feed, shelter, and attempt to treat dozens of people.

The procurement alone was a feat. Philadelphia’s commercial infrastructure had collapsed with the exodus. Wholesalers had closed. Druggists had fled or died. The markets that supplied the city’s daily needs were shuttered or operating at a fraction of their capacity.

Girard used his own credit, his own network of contacts, and his own funds to obtain what the hospital required. He paid for things himself when the committee’s treasury could not move fast enough. He hired staff, fired staff who would not work, and established the routines that an institution requires: meal times, supply rotations, cleaning schedules, the mundane architecture of order that distinguishes a hospital from a warehouse of the dying.

The merchant’s efficiency was visible in the changes at Bush Hill within days of his arrival. Patients who had been lying on bare floors were moved to beds. Kitchens that had stood cold began producing food. The building was cleaned, room by room, and the worst of the filth that had greeted the first patients was scrubbed or burned away. Girard kept accounts the way he kept them in his counting house: methodically, precisely, with an eye to what was spent and what was received. The committee’s minutes recorded the transformation in the language of ledgers. Bush Hill was becoming, under a merchant’s hand, something that resembled a functioning institution.

But a hospital requires more than management. It requires a medical regime, a theory of what the disease is and how the body should be treated for it. The second appointment placed Bush Hill on a collision course with the medical orthodoxy that Benjamin Rush had established in the city.

The physician was Jean Devèze. He was a French doctor, trained in the medical traditions of France and the French Caribbean, where yellow fever was a known disease, a recurring visitor to port cities that traded with the West Indies. Devèze had experience with the fever that Rush, for all his learning, lacked. He had seen it before. He had treated it before. And the treatment he practiced was the opposite of what Rush was prescribing across the city.

Rush’s regime was heroic. He bled his patients, sometimes repeatedly, removing quantities of blood that left them faint and pale. He purged them with calomel and jalap, powerful laxatives that emptied the bowels violently. The theory was depletion: the fever was an excess, a morbid excitement of the vascular system, and the physician’s task was to reduce the body’s energies until the fever broke. Rush bled until the pulse weakened. He purged until the patient produced what he called “black bile.” He believed in this method with a conviction that bordered on the absolute. Patients who survived were evidence of the treatment’s efficacy. Patients who died were evidence that the treatment had not been applied early enough or aggressively enough.

Devèze did not believe in depletion. His method was palliative. He prescribed rest, fresh air, fluids, and gentle stimulation: wine, quinine, cold applications to reduce the fever’s heat. He dressed his patients in clean linen, kept their rooms ventilated, and administered what comfort he could. The theory was support rather than assault: the body was fighting a disease, and the physician’s role was to sustain the body’s strength while the fever ran its course. The French school had developed in the Caribbean colonies, where yellow fever was endemic and where physicians had learned, through long experience, that patients who were bled and purged tended to die more quickly than patients who were rested and hydrated.

The contrast between the two approaches was not academic. It showed in the patients. Rush’s patients lay in their beds, white and weakened, their arms bandaged from repeated venesection, their bodies exhausted by purgatives that kept them on the chamber pot. Devèze’s patients at Bush Hill lay in clean beds in ventilated rooms, sipping wine and water, their fevers managed with cooling cloths rather than attacked with the lancet. The two physicians were practicing in the same city, treating the same disease, with methods so opposed that one’s cure was the other’s poison.

Devèze’s appointment at Bush Hill was, in effect, a repudiation of Rush’s method by the committee that governed the city. The committee did not frame it that way. They were not medical men, and they were not in a position to adjudicate a dispute between physicians. But the practical effect of placing Devèze in charge of the city’s principal fever hospital was to establish an institution where Rush’s theories were not practiced, where the lancet and the purge were set aside in favor of care that aimed to comfort rather than to conquer. Bush Hill became, without anyone declaring it so, the anti-Rush hospital.

The stakes were not small. Rush was the most prominent physician in Philadelphia, a signer of the Declaration of Independence, a man whose reputation carried the authority of the republic itself. His medical opinions were treated, by many, as the opinions of a man who had earned the right to be right. To reject his method was to reject a figure of national standing. The committee did not reject him openly. They simply placed their hospital in the hands of a Frenchman who practiced differently, and let the results speak.

The results were difficult to measure in the first weeks. Patients arrived at Bush Hill in every stage of the disease, from the first flush of fever to the black vomit that preceded death. Some were already dying when the carts delivered them. Devèze could not save those. But among the patients who arrived early enough, who were placed in clean beds and given fluids and rest, a portion recovered that might not have under the lancet. The exact numbers were not recorded with the precision that Girard brought to his supply accounts. But the impression formed, among the staff and the committee, that Bush Hill was a place where people survived, and that survival was connected to the way they were treated.

Girard and Devèze worked in parallel, the merchant and the physician, each handling what the other could not. Girard managed the building, the supplies, the staff, and the money. Devèze managed the patients, the medicine, and the medical decisions. Their domains overlapped at the edges: a patient needed food, and the physician’s prescription determined what food; a room needed ventilation, and the merchant’s staff made it possible. They appear to have worked without friction, each respecting the other’s competence, each occupied with his own task. Professional collaboration under pressure, not friendship — the kind of arrangement that forms when two people share a problem too large for either to solve alone.

Girard’s contribution was not limited to administration. He walked the wards. He attended patients himself, performing tasks that no merchant of his standing would have been expected to perform in ordinary times: carrying water, changing soiled linen, holding the hands of the dying. The committee had asked him to manage the hospital. He did more than manage it. He inhabited it. He put himself inside the wards where the fever was thickest, where the air was heavy with the smell of sweat and vomit and the groans of the sick. He did this day after day, through September and into October, without contracting the fever himself. His immunity was a matter of luck, or of prior exposure, or of whatever combination of biology and circumstance determined who survived and who died. He did not know why he was spared. He continued to work.

The committee watched Bush Hill with the anxious attention of men who had staked their authority on its success. The hospital consumed money, supplies, and staff at a rate that strained the committee’s resources. Patients arrived faster than they could be accommodated. The estate’s capacity was finite, and the epidemic’s growth was not. The committee continued to meet, to allocate funds, to request support from neighboring cities and states, and to manage the dozens of crises that arose daily across a city with no functioning government above them. Bush Hill was their most visible project, the institution that demonstrated that someone was in charge, that the abandoned sick were not simply being left to die. It was also their most vulnerable, dependent on two men, a merchant and a French doctor, who could sicken and die like anyone else.

The hospital’s early days were precarious in ways that the committee’s minutes only partially captured. The staff was insufficient. Nurses were scarce in a city where nursing meant exposure to the fever and where most women who might have served as nurses had fled with their families. The patients needed feeding, washing, and turning, the relentless physical labor of caring for the bedridden. They needed someone to carry the dead out and bring the next sick in. The building needed cleaning that was not a one-time effort but a continuous process, as each new arrival brought new contamination and each death left a bed to be stripped and a body to be removed. Girard hired what staff he could find, paid what he needed to pay, and filled gaps with his own labor when no one else could be found. But the gaps kept opening.

The demand for labor at Bush Hill was not abstract. It was specific, daily, and physical. The hospital needed people who would enter the wards, handle the sick and the dead, and return the next morning to do it again. It needed people who would work through the night, carrying water and linen and bodies, in a building where the air itself was believed by many to carry the disease. The committee had no pool of workers to draw from. The white working class of Philadelphia had largely fled. The remaining population was depleted, frightened, and unwilling to expose itself in a fever hospital. The institution that Girard and Devèze had built was functioning, but it was starving for hands.

The resolution of this crisis would come from a source the committee had already begun to cultivate, a population that remained in the city when others had left, organized under its own leadership, and available for the work that no one else would do. During the 1793 yellow fever epidemic, Richard Allen and Absalom Jones organized Black Philadelphians as essential workers to care for the sick and manage the dead, responding to an appeal from Benjamin Rush. Amid fierce debates over the cause of the fever, Rush had approached the Black community’s leaders with a proposition rooted in a belief that would prove catastrophically wrong: that Black people were immune to yellow fever.

The Free African Society, under Allen and Jones, had already begun sending its members into private homes to nurse the sick. Now the institution at Bush Hill represented a concentration of the same need, scaled up, organized, and sanctioned by the committee’s authority. The hospital on the hill needed bodies, and the bodies it would get were Black ones, deployed under a promise of immunity that the disease was already disproving.

The first Black nurses to enter private houses had already begun to sicken by the time Bush Hill was functioning. The belief in their immunity, which Rush had promoted and which the committee had accepted as a practical basis for deploying them, was collapsing against the evidence of their own fevers. But the need did not diminish. It grew. The hospital at Bush Hill, the institution that Girard had organized and Devèze had staffed with medical care, could not operate without labor, and the labor it required was the most dangerous kind: direct, sustained contact with the fevered and the dying. The merchant had built the shell. The Frenchman had established the method. The institution stood on the hill, clean, ventilated, supplied, and understaffed, waiting for the people who would fill its wards with the work of caring.

Bush Hill was open. Its beds were filling. Its doors received the sick who had nowhere else to go, carried up the hill on carts that passed through streets emptied of everything but fever and death. The merchant walked the wards. The French physician moved among the patients with his cooling cloths and his wine. The committee counted the cost and allocated the funds. And the hospital, the city’s last institution of care, waited for the hands that would make it more than a building with beds in it. Those hands were already at work elsewhere in the city, in the houses of the sick and dying, and they were already beginning to fail.